THE DIAGNOSTIC DANCE

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1 THE DIAGNOSTIC DANCE The following case history is a transcription of a case presented by Jason Blalack in his Pearls of Chinese Wisdom Webinar: Writing Precise Prescriptions with Qin Bo Wei s 56 Methods. A video of the case history can be found at Simon Plant Jason Blalack. INTRODUCTION Dr Qin Bo-Wei ( ) was renowned for his clinical skills and had a pragmatic approach to clinical practice without being restricted to any one school or style and was able to synthesize complex and often contradictory theories into clear systematic ideas. Dr Qin was critical of the direction TCM took under Mao Zedong, which aimed to integrate Chinese Medicine into the Western Medical model, and believed that Chinese medicine should be rooted in the Chinese Medical Classics. Based upon his extensive clinical practice and detailed knowledge of the classics of Chinese Medicine, Dr Qin wrote Guidelines for Treatment (1953) synthesizing the most important ideas from the history of Chinese Medicine and organized them into 56 core treatment methods with key diagnostic criteria. The 56 methods of treatment were based to some extent on a summary of the teachings of Qin Bo Wei s teacher Ding Gan-Ren ( ) who was part of the Menghe current (1626 onwards). The key difference between this approach and more modern TCM clinical manuals is that rather than being organized by disease category or symptoms the book is arranged by treatment method. Dr Qin s treatment methods are based upon classical formulas and a deep understanding of the way of thinking behind a prescription. The following case study presents an ongoing treatment and demonstrates how to use Qin Bo-Wei s approach when dealing with a complex presentation. It illustrates the importance of adopting a simple and precise but flexible approach when treating complex cases. It also shows how customization of formulas can be a dynamic process reflecting the patient s response to treatment and how a patient getting worse does not necessarily mean one s core strategy is wrong. Initial Consultation A female patient presented with chronic fatigue syndrome and Hashimotos (autoimmune hypothyroidism). She felt fatigued and easily bloated after eating, which was worse with grains. She had gluten sensitivity. Her bowel movements were infrequent, round and did not fully void. Generally she felt cold, but warmer lately. She felt clammy and sweaty with red hands and slightly red face. Her sleep was poor with nightmares, she felt mentally restless, and she had palpitations. Pulse: Cun: Deep & Weak Guan: Floating Chi: weak Tongue: trembles, slightly dry with a pink body and teeth marks. The pulse, tongue and fatigue indicated qi deficiency and the gastrointestinal problems indicated qi and food stagnation. There are some apparent contradictory signs and symptoms: the patient felt cold but had red hands and face. It is important however to look at the global picture and not to be led astray by the signs of heat. In this case 26

2 the heat signs and mental restlessness were caused by secondary heat arising from the qi stagnation. When considering a treatment method it is important in this case to not address the heat signs directly unless it becomes a real issue. First treat the underlying pathology and then add heat clearing herbs if the heat does not resolve. Qin Bo-Wei s method emphasises a gentle approach, which in this case was especially important since the patient was very sensitive and could not tolerate acupuncture. Although the patient was deficient, because of the qi and food stagnation a Si Jun Zi Tang formula would have been too tonifying. Qin Bo-Wei s Reinforce the Spleen and Remove Food Stagnation method was used. Asterisk indicates core Qin Bo Wei Formula: (dosage in grams) Da Fu Pi was used for the bloating and to guide out stagnation through the stools, because the patient was deficient it was important not to purge. The Ji Nei Jin and Gu Ya were used to address the food stagnation and to rebuild the gut. Mai Ya was contraindicated because of gluten intolerance. Chai Hu was added to raise the Spleen qi and because of the possible involvement of the Liver in the qi stagnation. The Chai Hu, although cool, was not added to address the heat signs. The addition of the Chai Hu was slightly speculative but by keeping the formula small and tight it was possible to see how one or two herbs changed the presentation over time. Second Session Her appetite had improved, especially in the evening, and she was craving spicy food and drinking more water. She was less bloated overall but more constipated and took a laxative. The patient reported having a candida flare-up for the past two weeks (initial consultation was one week prior). To her this referred to essentially vaginal discharge. There was no change in her energy and she felt colder and was sweating and waking at night. Her nocturia (which she did not mention at the first session) resolved even though a Kidney tonifying formula was not used. This indicated that the stagnation in the middle jiao caused the nocturia, a pattern often seen in clinical practice. Pulse: overall slightly deep, rapid, slightly jumpy and slightly thin and weak especially in chi position. The improvement in appetite and less bloating indicated that the formula addressed the core pathology. Even though there were secondary heat signs and the pulse was slightly rapid, the vaginal discharge, fatigue and decreased sex drive reinforced the need for a warming method. Shan Yao Dioscoreae Rhizoma 9 Fu Ling Poriae Cocos 12 The vaginal discharge indicated dampness. Since the patient was sensitive a gentle approach of Fu Ling and Shan Yao was used, the astringent quality of the Shan Yao working on the Kidneys to treat the vaginal discharge. It should be noted that the Chai Hu was removed. How the patient responded provided key clinical information. Third Session The patient felt worse and unrested in the morning despite ten hours sleep and naps in the day. Her bloating was 40-50% improved but her appetite was low and she was eating less and did not feel like she was digesting food. She was constipated with small and loose skinny stools. She was thirsty but with no desire to drink. She was having nightmares, night sweats, and felt damp. Her face was flushed and clammy. Pulse: weak but all positions were palpable. Tongue: dry greasy coat Sometime clients will get worse during the treatment and this information can be used. Because small, clearly defined changes had been made to the formula it was easier to understand the change in the patho-dynamic. 27

3 Her bloating was still improving and this was positive so there was no need to change the core method. A key clinical decision needed to be made: were these damp or qi stagnation symptoms? Chai Hu was used in the first formula and removed in the second and damp draining herbs were added. This made things worse, providing useful information and highlighting why small changes in a formula are better. It was clear that the qi dynamic needed to be regulated more. Dampness was still an issue and a different method needed to be tried, but first the qi dynamic needed to be addressed. The constipation was a concern and the bowels needed to be regulated before tonifying. (Chao) Bing Lang Semen Arecae Catechu Prep. 6 Tian Hua Fen Radix Trichosanthis Kirilowii 9 Shan Yao and Fu Ling were removed and Chai Hu was reintroduced to regulate the qi dynamic. Dry fried Bing Lang was added, working together with Da Fu Pi to open the bowels. Tian Hua Fen was added because there were concerns about injury to fluids. Fourth Session The patient was no longer constipated, the bloating continued to improve, and she slept through the night. She had some nausea in the morning and this combined with her poor appetite indicated that the damp had not resolved. She also has had episodes of heartburn. (Chao) Bing Lang Semen Arecae Catechu Prep. 6 Tian Hua Fen Radix Trichosanthis Kirilowii 9 Bai Dou Kou Amomi Fructus rotundus 3 Sha Ren Amomi Fructus 3 Hou Po Cortex Magnoliae Officinalis 6 The Shan Yao and Fu Ling used in the second formula was not adequate, and a different but still mild approach was needed. A damp transforming method using aromatic Sha Ren and Bai Dou Kou was used rather than a damp draining method. Sha Ren and Bai Dou Kou helped with the poor appetite and worked on the Spleen and Stomach functioning. Hou Po was added to open up the qi dynamic and to move qi and damp. Fifth Session The nausea resolved and her appetite improved indicating that this was caused by dampness, which the Bai Dou Kou, Sha Ren and Hou Po addressed. Her energy improved and she had energy to go out at night. However, she felt restless and consequently reduced her thyroid medication. Because the formula addressed the core pathology, other signs and symptoms resolved. Her energy improved even though (except Bai Zhu) there were no Spleen tonics in the formula, her sleep improved even though there were no herbs to directly address this, and her heartburn resolved even though herbs such as Huang Lian and Wu Zhu Yu were not used. Her stools were still skinny and she was not emptying fully. A repeat formula was prescribed to consolidate the treatment and to see if the symptoms continued to improve. Bing Lang was removed because her bowels were moving. Sixth Session Symptoms continued to improve but her stools were thin. Chao Bing Lang Semen Arecae Catechu Prep. 6 Tian Hua Fen Radix Trichosanthis Kirilowii 9 Sha Ren Amomi Fructus 6 Hou Po Cortex Magnoliae Officinalis 6 Gua Lou Shi Fructus Trichosanthis 9 Xie Bai Allii macrostemi Bulbus 2 Zhi Gan Cao Radix Glycyrrhizae Preparata

4 Gua Lou Shi and Xie Bai were added to the formula. This herb pairing is used by Wu Bo Ping to address thin stools caused by a swelling in the intestines. The Xie Bai awakens the Large Intestine to improve its functioning. Bai Dou Kou was removed, Sha Ren was increase to 6g, and Zhi Gan Cao was increased to 4.5g Seventh Session The patient was feeling overall well. The stools were normal, she had improved energy, and her appetite was good, although still poor in the mornings. Her mind was restless and she further reduced her thyroid medication. She had some lower back pain but her sex drive increased despite the lack of Kidney tonics in her formula. The improvements in her thyroid function, despite the treatment strategy not addressing this directly, demonstrates the importance of treating the overall presentation, which had a lot to do with the qi dynamicrather than the disease category. Changes to the formula: Tian Hua Fen was removed, and Shan Yao was added to strengthen the Kidneys and slightly moisten. Eighth Session Her energy was still not 100% and there was still some damp present. The formula still contained Sha Ren but Bai Dou Kou was removed. Pei Lan was added to open the Spleen and aromatically transform dampness. Chao Bing Lang Semen Arecae Catechu Prep. 6 Shan Yao Dioscoreae Rhizoma 9 Sha Ren Amomi Fructus 6 Pei Lan Eupatorii Herba 4.5 Hou Po Cortex Magnoliae Officinalis 6 Gua Lou Shi Fructus Trichosanthis 9 Xie Bai Allii macrostemi Bulbus 2 Zhi Gan Cao Radix Glycyrrhizae Preparata 4 Her symptoms improved significantly and overall she was less food sensitive. Because the Spleen and Stomach had been repaired she was then able to tolerate a more nourishing strategy to address her Kidney deficiency. Conclusion The core Qin Bo Wei formula was retained throughout with modifications based on changes in the patient s presentation even if those changes were negative. When there is no change or negative change in a patient s condition this can be used diagnostically and the formula revised. This simple, flexible and dynamic approach can be used effectively when dealing with complex conditions and can facilitate communication and rapport with clients by engaging them with the clinical decision making process. About the Author Jason Blalack is an international lecturer and the translator, compiler, and editor of Qin Bo-Wei s 56 Treatment Methods: Writing Precise Prescriptions, with clinical commentary by Wu Bo-Ping (published in 2011 by Eastland Press). Having made numerous trips over the past decade to study closely with Dr. Wu Bo-Ping, one of Qin Bo-Wei s most intimate and long-standing students, as well as several other older generation doctors, Jason s approach embodies a style that precedes our modern TCM system. Jason is a graduate of the Pacific College of Oriental Medicine in San Diego and maintains a full-time practice in Boulder, Colorado. He is passionate about helping students and practitioners bridge the gap between this approach and our modern TCM model by clearly presenting a clinically oriented method of thinking. Follow Up Sessions 29

5 Report on Professor Qian Feng s Daoist Cooking Workshops Cambridge, London and Brighton November 2014 Prof. Qian Feng is an ambassador for Chinese medicine and culture with a diverse background and experience in Daoist medicine and cooking, music therapy and physics. He was born in Beijing in 1958 into a family lineage of Daoist medicine practitioners. He has worked for the China Ageing Development Foundation (CADF) assisting the government to develop social welfare, healthcare, cultural, sports and education programmes for the elderly. He is the Director of the Beijing Digital Music Research Centre, and participated in projects for the Beijing Olympic Games Organizing Committee including the use of music therapy in athletic performance. Recently he has been involved in the planning and co-ordination of a 60-episode documentary on the Huangdi Neijing produced by the Chinese Music Therapy Association. Prof Qian also has a strong interest in food therapy and came to the UK last November, giving presentations in London, Cambridge and Brighton on his understanding of Daoist cooking. What follows is a summary of some of the main thoughts and comments that emerged from his talks. Daoist approach to Treatment First follow the Dao and then when necessary apply medicine to return to the Dao. When treating the emphasis should first be on slowing ageing, secondly preventing incoming illness from outside, thirdly understanding the constitution of your patient and preventing what might emerge from their predisposition, and finally treating the disease when it arises. Treatment consists of harmonizing the patient with heaven and earth and aligning a patient with their environment. Many illnesses arise due to inappropriate living, which includes eating the wrong thing at the wrong time and exercising in the wrong way at the wrong time. Daoists understand that particular foods are necessary at particular times, though in modern societies it is difficult to maintain this regime and live out our allocated life-span because our environment is very contaminated. It is important that doctors understand their patients habits and history then apply the appropriate medicine. Daoist doctors look deeply at the patient and do not just treat the disease. Self-Cultivation A Daoist practitioner is a universal human multitalented, using food, incense, music, Qigong, painting and other cultivation arts to help patients. Doctors must keep themselves very healthy in order to be able to diagnose a patient clearly, and they never stop learning and working on self-development to ensure that they are in the best condition to help their patients. Doctors should also attune themselves to the environment that they practice in to understand regional illnesses and investigate local herbs and foods that can be incorporated into their treatments. Eating Seasonal and Local Food Oat porridge is the best breakfast to eat in the UK and can be eaten all year round, but changing added ingredients to suit each season. In the spring you can use pungent ginger and chives to introduce the outwards and upwards energy of spring. In the summer add greens to porridge and make the porridge thinner and more like congee. In the autumn, add fresh salmon and in the winter eat lamb because it is very yang in nature. Long Yan Rou (Longan Fruit) and walnuts are very good in porridge in the winter. It is important to eat small mouthfuls of food mindfully generating lots of saliva and to eat lightly in evening as our energy winds down. 30

6 Medicinal Soups Soup is suitable for most constitutions and ingredients should be added and subtracted according to individual constitution and the season. The order in which ingredients are added when cooking is also very important. Below is a basic soup recipe from my family: First heat the oil and in the winter add black pepper to the oil to warm the interior. Start with ginger and spring onions as their pungent flavour reflects the spring and then add meat or mushrooms. Alcohol can now be added. Using the principle of eating locally, in the west whisky is ideal and is especially good for the Kidneys and to regenerate Yuan Qi. The ingredients in the pot should be very hot before adding the whisky and you should hear a very loud steaming sound when it goes in. Next add root vegetables and close the lid. Root vegetables are considered most important in Daoist cooking and 50% of our diet should be root vegetables that are full of vitality. Next add ingredients growing above soil, such as celery and greens. Then add vinegar to help preserve the essence in the food. Then add salt and finally boiled water. Water, which can also be in form of stock, should be added only at very end. Finally you can add coriander before serving but don t put the lid on the pan as the aroma and qi needs to rise up. Coriander is good at lifting the clear qi of the spleen and benefits the head. Salt should first be roasted first in a wok until the colour changes. Sea salt is very damp, cold and yin so gently roasting over a medium heat adds yang and also purifies it. Tea Tea is an important medicine. When it is roasted, prepared and infused with hot water it generates precious yang qi which is released into the body. It is important to leave some space in the cup to allow the aroma to circulate and to smell the tea frequently to open the orifices. Green tea helps our energy to ascend and reflects the nature of spring, red tea is the most balanced and particularly beneficial for women. Puerh and black teas are best drunk in the winter as their nature is to store. Tea should be sipped in small amounts to appreciate and savour the substance. Simon Plant EASTMEDICINE SUMMER SCHOOL Following the success of previous events, we are pleased to announce the 3rd EASTMEDICINE Summer School, July We offer you: seven days of research-based and clinically oriented seminars and practical workshops teaching by leading academics and experienced clinicians in the field of Chinese and East Asian medicines. Topics addressed include: treating chronic pain traumatic injuries electro-acupuncture self-cultivation (yang sheng) blood in the history of Chinese medicine, and much more. If you want to improve your clinical skill or learn more about the tradition, this is an event not to be missed. Seminars and workshops can be booked on their own, in any kind of combination, or as a full seven-day summer school. For further information and booking please contact: EASTMEDICINE Summer School Alison Braithwaite T: +44 (0) E: westminster.ac.uk/eastmedicine/events Image: Wellcome Library, London 31

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